Deed poll
Dated
Notice for the London Gazette on change of name for an adult
D D
/
M M
/
Y Y Y Y
D D
/
M M
/
Y Y Y Y
NOTICE is hereby given that a Deed Poll dated
and enrolled in the Senior Courts of England and Wales on (leave blank)
Applicants new name
Applicants address
Single Married/Civil Partnership
Widowed Divorced/Civil Partnership dissolved
Abandoned the name of
(APPLICANT’S OLD NAME)
and assumed the name of (APPLICANT’S NEW NAME)
D D
/
M M
/
Y Y Y Y
(If applicable, Solicitors details)
LOC025
02.12
British Citizen British Dependent Territories Citizen
Commonwealth Citizen
Under section of the British Nationality Act 1981
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